ENS 43288

v t e ENS Event
05:00 Apr 4, 2007
Title	Improper Applicator Length Leads to Wrong Dose
Event Description	St. Vincent Hospital, (Green Bay, Wisconsin) notified [the state of Wisconsin] of a medical event by telephone, on April 5, 2007. The medical event occurred on April 4, 2007 and involved an HDR unit. Initial information indicated an incorrect length of catheter was used during the treatment. A [state] inspector was dispatched to the facility on April 6, 2007. On April 4, 2007, a patient was scheduled for a single-fraction interstitial treatment using a Varian Vari-Source HDR unit containing 6.24 Curies of Iridium-192. The patient was to receive 900 centigray to the vagina. An incorrect applicator length (100 cm) was input into the treatment plan. The actual applicator length was 120 centimeters. The source is believed not to have entered the patient's body during treatment. The authorized user and the patient were notified, and the patient will return for retreatment on April 12. The licensee is performing their own investigation into the event, including a reenactment of the event. A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 43288 +/-
Where
St. Vincent Hospital Green Bay, Wisconsin (NRC Region 3)
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+55.45 h2.31 days <br />0.33 weeks <br />0.076 months <br />)
Opened:	Paul Schmidt 12:27 Apr 6, 2007
NRC Officer:	Pete Snyder
Last Updated:	Apr 6, 2007
43288 - NRC Website
v • d • e

v t e Emergency Notification System
St. Vincent Hospital with Agreement State
WEEKMONTHYEAR2011-05-15T05:00:00 [Table view]
[ENS list for St. Vincent Hospital]

Navigation menu